The Centers for Medicare and Medicaid Services (CMS) has finalized a proposed rule that will eliminate reimbursement for X-rays taken for a chiropractor by a nontreating physician, such as a radiologist.
Chiropractors will still be able to refer patients back to any treating physician, such as a primary care doctor, for any X-rays that might be needed. The rule, which takes effect Jan. 1, 2008, states:
Diagnostic X-Ray Tests, Diagnostic Laboratory Tests, and Other Diagnostic Tests: Conditions (§410.32(a)(1)):
Section 1861(r)(5) of the Act was amended by section 4513(a) of the BBA to allow Medicare payment for a chiropractor's manual manipulation of the spine to correct subluxation, without requiring the subluxation to be demonstrated by an x-ray. The BBA provision was effective for services furnished on or after January 1, 2000. Prior to this statutory change, the subluxation was required to be demonstrated by an x-ray. Because chiropractors are limited by statute in the services they can provide under Medicare, it was necessary to create an exception to the requirement that diagnostic services (including x-rays) must be ordered by the treating physician as provided in §410.32(a). This exception, which permits a physician who is not a treating physician to order and receive payment for an x-ray that is used by a chiropractor, is specified in §410.32(a)(1).
Because of the BBA change, which removed the requirement that subluxation must be demonstrated by an x-ray, the so-called "chiropractic exception" at §410.32(a)(1) is no longer warranted. We do not believe it is necessary or appropriate to continue to permit payment for an x-ray ordered by a nontreating physician when a chiropractor, not the ordering physician, will use that x-ray. Therefore, we proposed to revise §410.32 by removing paragraph (a)(1) and redesignating paragraphs (a)(2) and (a)(3) as (a)(1) and (a)(2), respectively...
We believe that retaining the chiropractic exception would be inconsistent with the statutory provision at section 1861(r)(5) of the Act which defines a chiropractor as a physician only for the purposes of sections 1861(s)(1) and 1861(s)(2)(A) of the Act and only with respect to treatment by means of manual manipulation of the spine (that is, to correct a subluxation). This statutory provision does not include diagnostic services at section 1861(s)(3) of the Act, which is the benefit category under which x-rays are covered under Medicare. In addition, commenters noted that x-rays are not required to identify subluxations; rather, commenters stated that they use the x-rays to rule out other conditions where manual manipulation of the spine would be contraindicated or for which further imaging studies are indicated. While the use of x-rays for this purpose is outside the scope of covered chiropractic services, it is also not addressed by the chiropractic exception at §410.32(a)(1). The chiropractic exception only permits a non-treating physician to order an x-ray to identify a subluxation. Therefore, we are finalizing our proposal to revise §410.32 by removing paragraph (a)(1) and redesignating paragraphs (a)(2) and (a)(3) as (a)(1) and (a)(2), respectively, so that it is consistent and conforms to the statutory revisions mandated by the BBA.
As might be expected, the American Chiropractic Association (ACA) had a swift response to the rule announcement. ACA President Glenn Manceaux, DC, told the press, "CMS put politics in front of patient care when it approved the recent changes to chiropractic X-ray reimbursement. Despite receiving hundreds of pleas in opposition, federal bureaucrats moved forward and finalized the proposed rule. Be assured that ACA will continue to fight implementation of this ill-advised decision. ... While the new rule clearly is not good for patients, doctors of chiropractic remain committed to providing the safest, highest quality care for Medicare beneficiaries."
The ACA's complete response to the CMS rule can be found at: www.acatoday.org/userImages/File/ COMMENTS_ACA_CMS1385_FINAL.pdf.
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